Abstract

Aims: To evaluate how often children seen in paediatric accident & emergency (A&E) departments were suspected of abuse or neglect,
and to explore some of the correlates of suspected child maltreatment.

Methods: Multicentre, cross-sectional study of 15 randomised census days during a six month period. Trained research assistants working
with local paediatric staff completed a purpose made anonymised checklist covering sociodemographic and medical information.
A six point suspicion index was used to rate compatibility with child maltreatment based on the occurrence of observable harm.
Statistical analysis was carried out on the basis that a score of 4 or more was suspicious of child maltreatment. Nineteen
hospitals provided standardised paediatric A&E consultation data on 0–14 year olds presenting between 10 am and 10 pm.

Results: Of 10 175 assessed children, 204 aroused suspicion of child maltreatment (95% CI 163 to 214 per 10 000). In a logistic regression
model of suspected maltreatment statistically significant associations were found with socioeconomic disadvantage, children
living in single parent families, and developmental delay. There was no correlation with pre-school age, male gender, foreign
origin, or living in urban areas.

Conclusions: Child maltreatment based on immediate scoring of suspicion, focused on observable harm, occurred in 2% of a representative
sample of paediatric emergency consultations in Italy. This was more common if there were associated social and developmental
vulnerabilities. True prevalence of child maltreatment in emergency departments remains elusive because of changing definitions
and forensic validation problems.

Child abuse and neglect represent a major public health concern, not only for the detrimental effects they have on children’s
health, but also for the damage to families provoked by false allegations. This is reflected by the increasing prominence
of this problem in the media and judicial system. The true prevalence of child maltreatment anywhere in the world remains
a matter of speculation.

In Italy a self-reported rate of 8% for severe physical violence emerged from a population survey carried out anonymously among 2388 families living in Tuscany.1 If these figures are accurate, obvious ethical imperatives arise. As long as access to hospital accident and emergency departments
(A&E) is free, and children can be “self-referred” by parents, teachers, and carers, there are important opportunities for
detection of child maltreatment and timely intervention. However, in order to plan for an effective screening strategy for
child maltreatment presenting to A&E departments, it is necessary to have an idea of the expected size of the suspicion (or
positive predictive value) generated by such programmes.

Aiming to evaluate how child health professionals engaged in routine A&E examinations become concerned about child abuse and
neglect, the Italian National Institute of Health (Istituto Superiore di Sanità) promoted a multicentre epidemiological study
to estimate the prevalence and describe some characteristics of suspected maltreatment in 0–14 year old children presenting
to A&E for any reason.

METHODS

Sample and assessment

The study included 19 hospital A&E departments ranging from large teaching hospitals to medium sized suburban hospitals. There
were 13 general hospitals and six specialist children’s hospitals. The annual flow of A&E paediatric consultations ranged
from about 5000 per year at Vimercate Hospital, Milan, to over 50 000 at Santobono Hospital, Naples. In Italy all children
attending A&E departments are seen by paediatric medical staff before leaving the hospital.

Research assistants were trained to complete a screening checklist summarising the clinical notes of all children up to age
14 seen in A&E for any reason between 10 am and 10 pm, on 15 days randomly selected by computer over a six month period, done
in such a way that any weekday occurred at least twice. Information was sought from the accompanying adult(s) and completed
by direct clinical observation. The checklist included the items shown in tables 1 and 2. Child protection agencies were expected
to be alerted in relation to cases that aroused suspicion of maltreatment independent of the study procedures. Complete physical
examinations were performed whenever possible, especially in younger children.

Index of suspicion

The main outcome variable was a six point ordinal scale assessing the possibility of child maltreatment, defined as probable
or definite child physical or sexual abuse or severe neglect. A concept of compatibility was used, rather than risk assessment, so that any confusion with statistical language was avoided.

The compatibility measure ranged from 1 (no suspicion) to 6 (definite child abuse or neglect). Local child health teams made
their assessments in collaboration with the research assistants and jointly attributed the score. Clinicians did not know
that 1–3 would be considered to be negative, and 4–6 positive for suspicion of maltreatment in the statistical analysis. Different suspicion thresholds would obviously yield different prevalence estimates
(not necessarily different correlations).

Informed consent

The data were anonymised at an early stage of the study process. The ethical committees of the relevant institutions fully
evaluated the research protocol. The study panel was told that, according to the Italian laws, they did not deem necessary
a formal approval because individuals’ names were not filed or processed electronically in any way, and information concerning
the identity of the patients was not stored.

Statistical analysis

Data were collected on single sheet forms, then captured as dichotomous variables and processed using Microsoft Access and
SPSS and STATA 5 software. χ2 tests were applied to compare suspected positives and negatives (with Yates’s correction for small frequencies). The association
between number of patients and number of positives was examined with parametric and non-parametric tests to assess whether
patients’ volume influenced suspicion rate. A multivariate analysis was used to further explore how positives and negatives
differed in terms of maltreatment risk. Odds ratios were derived for each sociodemographic characteristic associated with
child maltreatment. The logistic model was run on STATA 5, entering seven variables in the following order: age up to 4, male
gender, foreign nationality, urban residence, socioeconomic disadvantage, single parent family, and development (cognitive
and/or emotional) delay.

RESULTS

Sample characteristics and missing data analysis

The study took place between April and September 2000. Pooling the 15 index days, the total number of consultations that took
place in the participating A&E departments was 10 955. This sample was assumed to be approximately representative of the 264
000 A&E paediatric consultations occurring in the 19 participating hospitals in the year. About 50% of the actual sample was
enrolled in June and July (summer school term ends by mid-June in Italy). Ninety two per cent of consultations occurred on
the randomised calendar dates, while the remainder were recorded on alternative (but same weekday) dates to make up for unanticipated
local key staff days off. Overall, weekend consultations accounted for 39.1% of the sample. The largest number of consultations
was provided by the Children’s Hospital Santobono, Naples (n = 2160), accounting for 19.7% of the sample. Two cities, Naples
in the south (two hospitals), and Turin in the north, contributed one third of the sample. Remaining cities, ranked by sample
size, included Rome (two hospitals), Milan (three hospitals), Genoa, Bari, Ancona, Trieste, Alessandria, Padoa, Rimini, Bologna,
Modena, Cagliari, and Novara.

The outcome variable (that is, maltreatment compatibility score) was missing in 780 cases (7.1%), mainly due to high numbers
of emergency cases, making reliable scoring impossible. Consequently, the number of valid evaluations was 10 175. There were
751 (7.4%) consultations in which joint evaluations of the outcome variable by paediatricians working in A&E and research
assistants were not possible due to high caseloads. There was no statistically significant sociodemographic difference between
the excluded patients and the remainder of the sample.

The mean age (SD) of the patients was 4.8 (3.9) years. However, 57% of consultations were for children under 4. Fifty seven
per cent were males. The distribution of suspected maltreatment varied significantly between hospitals (fig 1, χ2 p < 0.001).

Child maltreatment suspected by paediatric emergency staff (%). Approximate locations of participating hospitals and ratios
of children scoring 4 or above in “compatibility with the concept of child abuse or neglect, understood as physical, sexual,
or mental harm (i.e. non-subjective evidence of injury suffered because of others, known or unknown)”. Scale: 1, ruled out;
2, almost excluded; 3, very dubious; 4, dubious; 5, almost certain; 6, certain. Clinicians did not know what threshold was
to be set.

Frequency of suspected child maltreatment

The maltreatment compatibility score showed a skewed distribution, with 9426 scoring one, 369 scoring two, 142 scoring three,
125 scoring four, 47 scoring five, and 32 scoring six. There were 204 consultations (2%) indicating maltreatment based on
a score of 4 or more. There was no significant difference in suspicion frequency between census and catch-up dates (table
1). Including missing data patients in the overall denominator, the point estimate translates into a 95% confidence interval
of 163 to 214 suspect victims per 10 000 consultations per year.

Figure 1 shows hospital positive ratios on a drawing of the country, ranging from 0% to 11.1%. There were statistically significant
differences between hospitals (χ2 p < 0.001). Local sample sizes, however, were not significantly associated with positives frequencies.

Table 1 compares the sociodemographic characteristics of those scoring positive for suspected maltreatment against the remaining
sample. These characteristics included male gender, nationality, socio economic status, one parent family, and residence in
towns with over 15 000 inhabitants. All these variables, except male gender and urban residence, were significantly more frequent
in suspect cases (p < 0.001).

Higher frequency of suspicion was significantly associated with A&E attendance in the previous year, the episode commonly
being an accident and/or a history of contact with family support teams or child mental health services (p < 0.001).

Table 2 details the proportions of skin, oral, and genito-perineal lesions of possible traumatic cause, as well as evidence
of present or past fractures, burns, and head trauma. Except for burns (p < 0.05), suspicion distribution was statistically
significant for all these characteristics at the 0.001 level.

The three most frequent A&E presentations were fever, head trauma, and inguinal pain. Following paediatric assessment about
6% of children were admitted to hospital wards in both groups. Medical histories were felt more often incongruous in children
with suspicion of maltreatment than in the remaining sample (p < 0.001). Similarly, circumstances relating to the reason of
consultation were considered preventable or due to carers’ unawareness, imprudence, or insufficient supervision of the child
more often in suspicious cases (p < 0.001). Of the 165 of 200 suspected cases where evaluation was possible, 82.5% were ascribed
to neglect and the remainder as due to sexual or physical abuse.

Clinical correlates of child maltreatment

The outcome variable was not derived from other items, and its correlations were explored by multivariate analysis based on
8624 records (1551 excluded due to missing data). The analysis included age, gender, nationality, urban versus rural residence,
social disadvantage, family composition, and developmental delay. The model’s overall variance was statistically significant
(table 3). Age, gender, nationality, and living in urban areas were not statistically significantly associated with suspicion
of maltreatment in the multivariate model (whereas the association with nationality appeared significant in the bivariate
statistic of table 1). However, socioeconomic disadvantage, single parent family status, and cognitive or emotional delay
were significantly associated with likelihood of maltreatment suspicion even after controlling for age, gender, nationality,
and residence.

DISCUSSION

Independent of the aims of the study, child protection agencies were alerted to the 32 (of 10 175) cases that scored highest
for child maltreatment based on observable clinical harm. This indicates a formal maltreatment-allegation rate five times
higher than the rate found in a retrospective survey of clinical records in 68 A&E units across 16 Italian regions in 1998,
which was 6 per 10 000 (252/410 566).2

Based on the clinical suspicion threshold set in the current study, the observed 2% is intermediate between those reported
in other A&E surveys carried out in other countries, which yielded rates of 60 per 10 000,3 1.3%,4 and 4%5 (the former study considered children up to 2 years of age; the latter two studies only included children referred for trauma).

Besides population variability, higher A&E alleged maltreatment rates could be explained by participation in research and
using flowchart-style reminders in the assessment notes, to help increase the awareness, consideration, and documentation
of injuries to children.6 Audit has been shown to increase staff awareness of the possibility of child abuse.7 In nine A&E surveys from different countries, mainly based on notes reviews, the median rate of maltreatment was 110 per
10 000 (sample sizes ranging from 642 to 26 779, median 11 066).8–15 The suspicion rate exposed in our study is twice that.

This study was unique in getting clinicians to record how many children had suspected maltreatment, and why, before allegations were made and child protection schemes activated. It is an important contribution to the epidemiology
of child maltreatment. The study showed a suspected maltreatment rate of 200 per 10 000 consultations (95% CI 163 to 214).
With a definition stressing the concept of compatibility with abuse or neglect, and the occurrence of observable clinical harm, 1 in 50 children were suspected of maltreatment. This
is a major challenge for emergency departments.

The study confirms and reinforces that developmental delay and incongruity between observed injuries and the history are significantly
associated with suspicion of maltreatment in the A&E paediatric setting. Hospital effect was not included in the multivariate
model of suspicion because the study focused on patient related characteristics. Clinicians’ variability in addressing child
protection issues is well recognised.6

What this study adds

Two per cent of consultations in Italian emergency departments aroused clinical suspicion of child maltreatment

Children’s age, gender, living in urban residence, and nationality were not linked to suspicion of child maltreatment

Child maltreatment was more likely to be suspected along with developmental delay when accounting for sociodemographic factors.

Study limitations

During the preparatory stage of the study many methodological problems were addressed, including the validity of the outcome
measure and the reliability of the checklist. Wording was painstakingly reviewed, and terms such as risk (in a non-statistical sense) dropped in favour of compatibility and suspicion. The six point scale of compatibility with maltreatment did not measure child maltreatment per se, but rather reflected clinicians’
perceptions during routine assessments. Its credibility and validity can be inferred from its correlation to sociodemographic
and clinical characteristics known to be associated with maltreatment.

The representativity of the study is limited to children attending A&E in the selected hospitals. Training and local discussion
of implementation was used to reduce variability in scoring. This was further reduced by research assistants and local paediatricians
jointly agreeing the compatibility score, where possible.

Not all consultations could involve full physical examinations, particularly in older children. More meticulous assessments
would not necessarily lead to higher suspicion counts. In any case they are unachievable in hectic A&E settings. The statistical
analysis had to deal with missing data compromising between using available information and minimising spurious associations.

It is of note that developmental (cognitive and/or emotional) delay was the overall clinical characteristic most correlated
with suspected maltreatment. However, maltreatment may cause developmental delay, or developmentally delayed children may
bring their (often poor and single) parents or carers to the end of their tether.

Conclusions

Emergency departments play a pivotal role in detecting child maltreatment. This paper provides epidemiological information
about the positive predictive value of a screening programme for child maltreatment in a defined setting, that is the occurrence
of suspected child abuse and neglect based on clinicians’ perceptions of compatibility with maltreatment using a simple score.
A 2% suspicion rate may or may not reflect how many children are indisputably victims of maltreatment within an exact clinico-legal
definition. Suspected cases were often characterised by delayed development, social disadvantage, and single parent household.
The high incidence of suspected child maltreatment in emergency departments presents both a challenge and an opportunity to
public authorities responsible for protecting children.